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COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD     , 


HX64119360 
RC66  . D65  Outlines  lor  case  ta 


RECAP 


MEDICAL  CLINIC 


THIRD  EDITION 


GEORGE  DOCK 


OUTLINES 


'FOR 

CASE  TAKING 

AND 

Routine  Ward  and  Laboratory  Work 

AS  USED  IN  the; 
MEDICAL  CLINIC 

OF  THE 

WASHINGTON    UNIVERSITY 

BY 

GEORGE  DOCK,  A.M.,  M.D.,  Sc.D. 

Professor  of  Medicine,  Washington  University 

St.  Louis,  Mo. 


(Third  Edition  Revised) 


George  Wahr 
Publisher 

ANN  ARBOR,  MICH. 


COPYRIGHT   1902 
COPYRIGHT   1 9 13 

COPYRIGHT    192 1 

BY  GEORGE  WAHR 


1?  C  CG 

Dcr 


THE  ANN    AReO"?    PRESS 


PREFACE 

These  outlines,  based  originally  on  Strum- 
pell's  Leitfaden,  have  long  been  used  in  my 
clinic  in  type-written  copy  as  guides  in  case- 
taking.  Being  intended  merely  as  outlines, 
methods  are  not  included.  Laboratory  manip- 
ulations necessary  in  the  study  of  cases  are 
for  the  most  part  familiar  to  the  student  when 
he  begins  clinical  work.  Hand-books  are  avail- 
able in  the  clinical  laboratory  and  should  be 
consulted  freely. 

1902. 

Preface  to  Second  Edition 

The  first  edition  of  this  little  work  has  been 
used  with  considerable  satisfaction  in  practical 
work  in  the  medical  wards.  In  preparing  the 
present  edition  I  have  profited  by  experience 
in  previous  years  and  have  also  had  the  val- 
uable assistance  of  Doctor  J.  S.  Brotherhood 
in  adding  material.  I  am  especially  indebted 
to  Doctor  Ernest  Sachs  for  additions  and 
improvements  in  the  neurological  section. 

1913. 

Preface  to  Third  Edition 


The  revision  of  this  guide  to  case-taking 
has  unavoidably  increased  its  size,  but  it  is 
hoped  the  enlargement  will  not  lessen  useful- 


—  4  — 

ness.  As  in  previous  editions,  compactness  is 
sought  by  giving  a  general  outline,  Avith  skele- 
ton additions  for  cases  found  to  belong  to 
special  categories,  as  well  as  for  special  exam- 
inations. 

In  order  profitably  to  use  the  book  the  begin- 
ner must  have : 

1.  A  general  knowledge  of  internal  diseases; 

2.  Facility  in  elementary  laboratory  technic ; 

3.  The  foundation  of  p^hysical  diagnosis. 

The  beginner  should  read  the  book  in  order 
to  know  where  to  find  needed  information,  and 
follow  it  in  the  actual  work  of  taking  histories 
until  the  act  becomes  unconscious.  Telegraph 
style  should  be  used. 

It  is  a  pleasure  to  acknowledge  the  con- 
tinued assistance,  often  unconscious,  of  many 
colleagues,  assistants,  and  undergraduates,  and 
especially  the  numerous  suggestions  of  my 
friend  Dr.  George  Herrmann,  Instructor  in 
Medicine,  University  of  Michigan. 

GEORGE  DOCK, 

June  21,  192 1. 


HISTORIES  ARE  NEVER  TO  BE  TAKEN 
FROM  THE  WARD 

Front  Page.     Fill  in  : 

General  Hospital  Number. 
Medical  Service  Number  (added  by  sec- 
retary). 

Patient's  name  in  full — no  initials  (e.  g.,  Smith, 
John,  Mary)  ;  sex ;  age  ;  married  ;  single  ; 
.  widowed  ;   divorced  ;   occupation  ;   nativ- 
ity; residence. 

Name  and  address  of  Patient's  nearest  relative 
or  friend  in  St.  Louis,  or  nearest  relative 
at  home. 

Name  and  address  of  Family  Physician.  If 
Patient  is  from  the  Hospital  Dispensary, 
give  service  number  and  date  and  get 
history  from  record  room. 

Date  of  admission  to  the  Hospital. 

Note  former  admissions  to  this  Hospital.  (Date 
of  Admission  and  Discharge,  Medical 
Number  and  Diagnosis.)  Read  former 
histories  and  abstract  important  data. 


Digiiized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/outlinesforcasetOOdock 


I.    FOR  MISCELLANEOUS  CASES  AND 
ACUTE  INFECTIONS. 

(For  special  diseases  see  Scheme  II,  etc.) 

1.  Name.     Put  patient's  name  at  top  of  each 

history  page.  Number  each  page  i,  2,  3, 
etc.    'Date  and  initial  each  note. 

2.  Patient's  complaints;  briefly  but  fully,  in 

original  words,  but  avoid  loose  expres- 
sions such  as  "kidney  trouble,"  "gastri- 
.  tis,"  etc. ;  or,  circumstances  and  con- 
dition in  which  the  patient  enters  clinic. 
If  delirious  or  too  weak  to  talk,  try  to 
get  particulars  from  those  who  bring 
him,  or  who  call ;  also  from  former  phy- 
sician, if  possible. 

3.  Family    History.      Health    or    causes    of 

death  and  ages  of  father  and  mother ; 
(of  uncles  and  aunts,  and  grandparents, 
if  indicated)  ;  ascertain  fullest  possible 
details,  with  special  reference  to  nerv- 
ous, metabolic,  ductless  gland,  and  blood 
diseases.  Clear  up  diagnoses  given  by 
histories ;  avoid  all  forced  conclusions ; 
use  "  "  for  unverified  diagnosis.  Broth- 
ers and  sisters  :  ages,  conditions,  causes 
of  death.  Children :  Number ;  ages ; 
health  of  each;  if  dead,  causes  of. 

4.  In    Women.      Menstruation.      If    married, 

how  long;  pregnancies;  abortions. 


—  8  — 

5-  Previous  History.  Condition  from  infancy, 
in  chronologic  order.  Inquire  especially 
as  to  complications  and  sequels  of  vari- 
ous diseases  in  turn.  Avoid  leading 
questions  as  far  as  possible;  also  sug- 
gestions of  symptoms.  Investigate 
especially  possible  relations  with  pres- 
ent disease — i.  e.,  scarlatina,  measles, 
Avhooping-cough,  typhoid  fever,  malaria 
(caution);  rheumatism,  influenza  (cau- 
tion), sepsis,  erysipelas,  diphtheria,  sore 
throat,  gonorrhea,  syphilis,  nephritis, 
endocarditis,  pleurisy,  pneumonia,  cho- 
rea, gout,  lead  poisonino-;  exposure  to 
epidemics.  If  there  is  a  history  of  any 
disease,  make  full  notes  as  to  duration, 
complications  if  any,  i.  e.,  scarlet  fever, 
ear  trouble  or  nephritis;  rheumatism, 
severity,  condition  of  joints,  of  heart. 
Scrutinize  all  diagnoses,  as  in  the  study 
of  the  present  disease. 

6.  Occupations   and  habits;   environment  of 

home  and  work  place;  kind  and  quality 
of  food;  regularity  of  meals;  mastica- 
tion; alcoholics,  substitutes  and  drugs 
in  detail;  tea;  coffee;  tobacco.  Avoid 
"light,"  "moderate,"  "heavy" ;  make 
definite  statements  of  amount  used,  and 
effects. 

7.  Investigation  of  the  sexual  life,  when  indi- 

cated. 


—  9  — 

8.  Present   Disease.     Date    (not   day  of  the 

week)  of  onset;  probable  cause,  in  opin- 
ion of  patient,  relatives  or  physician ; 
trauma ;  "cold"  ;  mental  or  physical  over- 
work ;  mental  shock ;  exposure  to  infec- 
tion ;  hygienic  conditions. 

9.  Mode  of  Onset.     Sudden  or  gradual ;  first 

symptoms,  as  chill,  fever,  pain :  location 
and  character ;  stomach  and  bowels 
(vomiting  in  acute  infection)  ;  weakness. 

10.  Later  Course.  Try  to  have  patient  de- 
scribe this  in  chronologic  order  and  in 
his  own  way,  but  seek  accuracy  and 
fulness.  Note  especially  the  following: 
Weakness,  loss  of  weight;  chills:  fever; 
thirst;  sweats;  headache;  vertigo;  sleep; 
lacrimation  ;  photophobia ;  pain  in  eyes : 
rhinitis,  epistaxis ;  mouth,  teeth  and 
gums ;  sore  throat ;  hoarseness ;  dyspnea ; 
cough ;  expectoration  ;  source  of  sputum ; 
palpitation  of  heart ;  appetite ;  degluti- 
tion; eructations;  nausea;  vomiting; 
flatulence ;  stools ;  urination  ;  frequency 
of,  amount ;  pain ;  alterations  of  men- 
struation ;  extremities,  sensations  in ; 
muscles,  bones,  joints;  edema.  Never 
fail  to  ask:    "Is  that  all?" 

Modifications  by  treatment  or  otherwise 
(avoid  critical  allusions  to  views  or 
treatment  of  former  physician). 


10 


11.  Present     Symptoms.       Summarize     these. 

Read  carefully  before  takin^j-  S.  P. 
(status  praesens)  and  ahvays  bear  in 
mind  in  making  later  examinatioijs,  and 
especially  on  discharge. 

12.  Physical  Examination.    Present  Condition 

(S.  P.).  Temperature;  pulse;  respira- 
tion  ("T.  P.  R."). 

13.  Body  in  General.    Habitus ;  height ;  frame, 

small;  medium,  or  large ;  slender  or 
heavy ;  symmetrical  or  not,  with  details 
in  latter  case ;  usual  weight ;  alterations 
in  weight ;  panniculus ;  musculature ; 
lymph  glands  ;  vertebrae  ;  ribs  ;  intercos- 
tal spaces;  long  bones:  joints;  flatfoot. 
Reflexes. 

14.  Position    (decubitus);    station;    gait;   tre- 

mor. General  appearance;  expression. 
Mental  condition  ;  Orientation  ;  vSpeech  ; 
memory  ;  attention  ;  apathy ;  coma  ; 
delirium;  carphologia ;  jactitation. 

15.  Skin.     Color  of  face,  bodv  and  extremities; 

visible  mucous  membranes ;  cyanosis ; 
icterus ;  skin  warm  or  cold,  dry  or  moist ; 
elastic  or  inelastic;  edema;  eruptions; 
ulcers ;  striae ;  scars ;  subcutaneous 
nodules.  Hair  of  head  and  other  parts. 
Nails. 

16.  Head.      Skull;   eyes;   ears,   tophi  and   dis- 

charge ;   cheeks ;   nose ;   accessory   nasal 


II 


sinuses  ;  herpes  ;  mouth  ;  teeth  ;  tongue ; 
soft  palate,  gums  and  buccal  mucous 
membrane  in  'general ;  tonsils  ;  adenoid 
tissue  ;  lingual  tonsil ;  pharynx.  Swab 
for  smear  and  culture. 

17.  Neck.      Shape;    size.      Larynx.;    thyroid; 

lymph-glands:  blood-vessels.  Torticol- 
lis. Tumors;  cysts;  fistulae;  scars  (ori- 
gin). 

18.  Thorax.     Shape  :  size  ;  type  of  respiration  ; 

diaphragm  phenomenon  ;  lagging,  retrac- 
tion ;  palpation,  percussion  and  auscul- 
tation of  lungs. 

19.  Heart.     Inspection  ;  position  and  character 

of  apex  beat;  thrill;  percussion;  auscul- 
tation.  Radial  pulse  ;  palpation  of  wall ; 
rate  (increase  on  sitting  up?);  size; 
rhythm;  tension.  Other  vascular  anom- 
alies, such  as  pulse  in  other  arteries ; 
veins ;  epigastrium ;  liver ;  capillaries. 
Blood  pressure. 

20.  Abdomen.     Form  ;  size  ;  floating  tenth  rib  ; 

visible  peristalsis;  eruptions;  palpation; 
pain  or  tenderness ;  succussion  ;  percus- 
sion (change  of  position).  Liver:  Per- 
cussion and  palpation ;  gall-bladder. 
Spleen  :  Percussion  ;  palpation.  Pylorus. 
Pancreas.  Appendix  region.  Pelvis 
(examine  by  A^agina  and  rectum  if  indi- 
cated). Perineum;  (hemorrhoids). 
Sites  of  hernia. 


12 


21.  Genito-urinary  apparatus:  Kidneys,  palpa- 

tion. Bladder,  palpation  and  percussion. 
Penis  :  Ulcers ;  scars  ;  discharge.  Scro- 
tum :  Varicocele ;  hydrocele ;  induration 
in  testes  or  cords.  Prostate;  seminal 
vesicles.  Vulva ;  vagina  ;  uterus ;  ova- 
ries; tubes. 

22.  Urine.     Amount;  sp.  gr. ;  color;  albumin; 

glucose;  sediment  and  "floaters."  (See 
VI.) 

23.  Blood.  Macroscopic  appearance  and  exam- 

ination of  fresh  drop ;  red  corpuscles ; 
leucocytes  ;  hemoglobin.  (See  V.)  Was- 
sermann  test;  blood  culture. 

24.  Stools.     Always  examine.     (See  IV.) 

25.  Sputum.    Type  pneumococci.     (See  II.) 

26.  Other   secretions   and   excretions.     Spinal 

fluid  in  suspected  meningitis.  Cultures 
and  animal  inoculations  of  exudates  and 
secretions. 

27.  Special  Examinations.     Tuberculin  tests; 

x-ray  filrns  of  teeth;  fluoroscopic  and 
skiagrams  of  thorax. 


—  13  — 

11.    DISEASES  OF  THE  RESPIRATORY 
ORGANS. 

3.  Family  History.  Investig-ate.  histories  of 
father,  mother,  brothers  and  sisters  with 
reference  to  all  possible  diseases  of  res- 
piratory organs,  and  to  tuberculosis  in 
various  forms.  Avoid  writing  doubtful 
diagnoses ;  if  necessary,  put  statements 
in  "  ".  Note  dates  of  illnesses  and 
deaths.  Add  histories  of  other  relatives 
if  clear  and  noteworthy. 

5.  Previous  Diseases,  etc.     Enlarged  glands, 

duration,  location,  severity;  bone  and 
joint  disease;  diseases  of  the  nose, 
throat,  larynx,  lungs  and  pleura. 

6.  Occupations,    etc.      Exposure    to    dust    or 

irritating  vapors,  grinding,  cold  storage, 
etc. ;  exhausting  or  depressing  occupa- 
tions; living  with  or  nursing  persons 
with  cough  or  tuberculosis.  In  women, 
..  puerperal  state. 

8.  Aspiration  of  foreign  bodies. 

9.  Onset.      Anemia;    anorexia;    emaciation; 

hoarseness;  aphonia;  cough;  expectora- 
tion ;  hemoptysis ;  weakness ;  fever ; 
chills  ;  diarrhea  ;  hemorrhoids  ;  bronchi- 
tis; pleurisy;  pneumonia;  amenorrhea. 

10.    Later    course:     Dyspnea;    night    sweats; 
fever ;  chills. 


—  14  — 

II.  Present  Symptoms.  Pain  in  thorax;  dura- 
tion, location;  character.  Cough,  time 
o£  occurrence ;  character,  dry  or  with 
expectoration ;  with  or  without  pain ; 
type  of  respiration ;  stridor. 

Expectoration.  Amount,  appearance,  con- 
sistency, odor. 

Blood  spitting.  How  excited,  amount, 
appearance. 

Dyspnea.  When  noticed,  character,  degxee. 

Larynx.  Pain  in,  how  excited,  as  by  talk- 
ing, swallow^ing,  singing;  voice,  altera- 
tions of. 

Alimentary  apparatus:  Compare  scheme 
for  Diseases  of  Organs  of  Digestion. 

Night-sv/eats. 

13.  Body  in  general:  Myoidema;  fingers  (club- 
bing) ;  nails. 

15.  Skin.    Flush  on  face;  pallor ;  traces  of  cya- 

nosis on  face  or  extremities ;  herpes ; 
dilated  veins  on  thorax. 

16.  Head.     Otoscope.    Al^e  nasi;  movement  of, 

larynx. 

17.  Laryngoscopic  examination ;  pharynx ;  root 

of  tongue ;  epiglottis ;  arytenoids;  poste- 
rior wall;  ventricles;   cords;  trachea. 

18.  Thorax.    Shape  in  general ;  (kyphosis ;  sco- 

liosis) ;  length;  breadth;  depth;  circum- 
ference (cyrtometer)  ;  interspaces  ;  epi- 
gastric   angle ;    Louis'    angle ;    clavicles, 


—  15  — 

supra-  and  infra-clavicular  foss?e;  ver- 
tebrae ;  symmetry ;  expansion ;  ratio  of 
in-  and  expiration ;  inspiratory  retrac- 
tion;  diaphragm  phenomenon. 

Percussion.  Always  compare  opposite 
side.  Note  volume,  pitch  and  quality  of 
sound  and  resistance  all  over,  and  espe- 
cially in  apices,  front  and  back;  height 
of  apices,  front  and  back ;  lower  boun- 
daries (Grocco),  with  mobility  on  respi- 
ration, and  change  of  position;  Traube's 
.  space. 

Auscultation.  Vesicular  breathing,  weak, 
exaggerated,  puerile  ;  broncho-vesicular  ; 
blowing,  soft  or  harsh ;  amphoric ;  ratio 
of  in-  and  expiration ;  breathing  after 
coughing. 

Adventitious  sounds.  Location  ;  character 
(crackling  rales,  fine,  medium  or  coarse; 
dry  or  moist ;  few  or  many ;  in-  or  expi- 
ration ;  rhonchi,  character,  location ; 
effect  of  coughing).  Friction;  location, 
character,  phase  of  respiration,  effect  of 
pressure,  position,  cough,  deep  breath- 
ing. 

Auscultation  of  voice.  Whispered  voice ; 
of  cough.  Auscultatory  percussion ; 
coin  sound. 

Palpation.  Vocal  fremitus  ;  friction  ;  pain 
or  tenderness ;  muscular  rio-iditv. 


—  i6  — 

ig.  Heart.  Pulmonary  second  sound ;  epigas- 
tric and  cervical  pulsations ;  dicrotic 
pulse. 

20.  Abdomen.        Spleen.        Liver.        Cojnpare 

scheme  IV. 

21.  Urine.     Tubercle  bacilli;  diazo  reaction. 

24.  Stools.     Pus;  blood;  tubercle  bacilli. 

25.  Sputum.      Quantity;    color;    consistency; 

character  (watery,  mucous,  muco-puru- 
lent,  purulent,  blood3^  rusty,  prune 
juice,  nummular,  layers)  ;  odor;  reaction. 

Cells  :  pavement  epithelial ;  alveolar  ;  dust-  ; 
heart-failure-;  leucocytes;  mononuclear; 
eosinophile.     Colloid ;  ''myelin." 

Red  blood  cells:  number;  condition. 

Elastic  tissue,  kind  and  quantity ;  Charcot- 
Leyden  crystals ;  hematoidin ;  fat-crys- 
tals; spirals;  bronchial  casts. 

Tubercle  bacilli,  number;  appearance;  in 
cells. 

Other  bacteria :  influenza ;  diplococci ; 
streptococci ;  staphylococci ;  strepto- 
thrix;  (actinomyces)  ;  yeasts;  molds; 
sarcines.  Spirochetes ;  (stain,  dark 
field).     Protozoa;  larvae;  ova. 

26.  Miscellaneous.       Exploratory     aspiration ; 

chemical  and  microscopic  examination 
of  fluids. 

27.  Bronchoscopy.      Fluoroscopic     and     skia- 

graphic  examination  of  lungs  and  pleu- 
rae.    Spirometer.    Vital  capacity. 


17 


III.    DISEASES  OF  THE  CIRCULATORY 
APPARATUS. 

3.  Family  History.     History  of  valvular  dis- 

ease ;  arterio-sclerosis ;  syphilis ;  apo- 
plexy; sudden  death;  family  tendency 
to  circulatory  disease. 

4.  In  Women.    Effect  of  possible  pregnancies 

on  the  course  of  the  disease  should  be 
borne  in  mind  in  connection  with  5. 

5.  Previous  Diseases.  "Rheumatism" ;  chorea 

(St.  Vitus'  dance)  and  all  acute  infec- 
tious diseases;  tonsillitis;  scarlet  fever; 
diphtheria  ;  pneumonia  ;  typhoid  ;  influ- 
enza :  syphilis ;  nephritis  ;  exophthalmic 
goitre, 

6.  Severe    manual    labor;    athletics;    excite- 

ment; over-eating;  excessive  use  of  alco- 
holics (beer)  ;  tobacco ;  coffee  and  tea. 

7.  Sexual  anomalies  and  masturbation. 

8.  Present  Disease.    Full  details, 

.  9.  Mode  of  onset.  Note  earliest  appearance, 
with  details  of  dyspnea ;  edema ;  weak- 
ness; palpitation  of  the  heart;  causes  of 
attacks ;  pain  in  heart  region,  with 
details  of  character,  radiation  (arm, 
head,  etc.);  intermittent  limping;  sub- 
jective feeling  of  heart,  character;  epis- 
taxis ;     cough,     expectoration ;     vertigo ; 


i8 


tinnitus  aurium ;  cyanosis;  pallor;  flush- 
ing ;  fainting- ;  sputum  (bloody)  ;  change 
in  quantity  of  urine.     Sleep.     Stomach. 

10.  Later  course  in  detail. 

11.  Present  Symptoms.     Subjective  symptoms 

in  full. 

13.  General.  Faulty  development  in  congeni- 
tal heart  disease  and  that  acquired  in 
early  childhood.     Clubbed  fingers. 

15.  Skin.     Combination  of  cyanosis  and. icte- 

rus ;  pallor ;  flushes ;  oedema ;  tropho- 
neuroses. 

16.  Head.       (Early    grayness    in    atheroma). 

Arcus  senilis;  conjunctival  vessels. 

17.  Neck.    Inspection  and  auscultation  of  arte- 

ries of  neck ;  pulsation  in  cervical  veins ; 
systolic  venous  pulse;  pulsation  in  jugu- 
lar fossae  (palpate)  ;  tracheal  tug ;  aus- 
cultation of  goitre.  Laryngoscope  for 
hoarseness ;  brazen  cough ;  aphonia 
(vocal  cord  paralysis). 

18.  Thorax.     Lungs.     Emphysema ;    pneumo- 

thorax ;  bronchitis ;  hydrothorax ;  con- 
gestion ;  infarct.  Diastolic  thoracic 
rebound. 

19.  Heart.     Inspection :    Prominence  in  heart 

region.  Apex  beat:  Location;  character; 
diffuse  pulsations;  retraction.     Epigas- 


—  19  — 

trium;  pulsations  in  other  parts  of  tho- 
rax (aneurysm;  pulsating  exudates.) 

Palpation.  Strongest  and  most  distinct 
location  of  apex  beat ;  force ;  heaving 
impulse ;  shock ;  rhythm.  Thrill  and 
friction  fremitus  ;  location  ;  time  ;  char- 
acter,. Palpation  of  other  pulsating  areas 
in  the  thorax.     Palpation  of  back. 

Percussion-  Outline  and  make  diagram. 
Percussion  of  cardiac  dulness  in  the 
back;  change  of  position. 

Auscultation.  Note  character  (weak, 
strong,  pure,  impure,  clear,  murmurish, 
accentuated,  snapping)  of  sounds  at 
apex ;  along  left  edge  of  sternum,  on  ster- 
num, to  right  of  sternum,  in  left  axilla, 
to  right  of  ensiform,  along  carotids  and 
subclavians,  in  back ;  rhythm ;  extrasys- 
tole.;  gallop  rhythm  (analyze)  ;  emibryo- 
cardia ;  auricular  fibrillation  or  flutter; 
alternating  beat.  Adventitious  sounds: 
■  Time,  character ;  w^here  best  heard ; 
transmission. 

Blood-vessels.  Visible  pulsations  in  arte- 
ries and  veins ;  capillary  pulse  in  nailbed, 
soft  palate  and  pharynx,  on  forehead ; 
pulsating  liver. 

Radial  artery.  Wall ;  course  ;  size  of  pulse  ; 
quick  or  slow ;  hard  or  soft ;  tension ; 
rate ;  rhythm.     Pulse  deficit. 

Auscultation    of    arteries.      Double    tone ; 


—  20  — 

murmurs    (note    effect    of  .pressure    on 
murmurs). 

Enlarged  veins  on  trunk ;  sketch  or  photo- 
graph.    Venous  tones  and  murmurs. 
Sphygmomanometer;  polygraph. 

20.    Abdomen.    CEdema;  ascites.  Liver.  Spleen. 

22.  Urine.        Complete     examination     as     in 

Scheme  VI. 

23.  Blood.     Full  examination.     Scheme  V. 

25.    Sputum  complete.     Scheme  II. 

27.  X-ray  examination  of  heart  and  sites  of 
aneurysm.  Seven-foot  skiagram  of  heart. 
Electrocardiograms.  Exercise  tests. 
Vital  capacit}^ 

IV.  DISEASES  OF  THE  ORGANS  OF  DI- 
GESTION (OESOPHAGUS,  STOMACH, 
INTESTINE,  LIVER  AND  PANCREAS). 

6.  Special  attention  to  habits  of  eating  and 
drinking.  Meal  hours ;  bolting  food ; 
eating  alone  or  in  company;  reading  at 
meals.  Condition  of  teeth ;  caries,  arti- 
ficial teeth;  care  of  mouth.  Quality  and 
quantity  of  food ;  proteid ;  carbohy- 
drates ;  fats ;  salt ;  milk,  how  taken. 
Water,  when  and  how  taken ;  temper- 
ature.    Tea;  coffee;  cocoa.     Alcoholics 


—  21  — 

in  detail.    Tobacco.    Work  and  exercise. 
Mental  anomalies. 

7.    Sexual  history  often  important,  especially 
in  neuroses  of  stomach. 

II.  Present  Symptoms.  Appetite,  degree  of; 
perversions ;  is  appetite  lost  or  recovered 
by  eating?  lost  after  a  few  mouthfuls? 

Thirst.  (Is  urine  in  proportion  to  water 
ingested?) 

Taste.  Normal  or  abnormal ;  disagreeable 
taste  in  mouth  ;  stale,  sour,  rotten,  sweet; 
dryness  of  mouth ;  burning  in  mouth. 

Saliva,  alterations  of. 

Swallowing.     Pain  ;  seat ;  character. 

Obstruction.  Apparent  seat,  change  of; 
constant  or  variable ;  to  what  kinds  of 
food,  liquid,  soft  or  solid?  Onset  and 
duration  of. 

Hemorrhage  from  pharynx  or  oesophagus ; 

time ;  character  of  blood. 

Feeling   of   pressure    in    stomach    region; 

exact  seat ;  relation  to  taking  of  food  or 
kind  of  food ;  duration. 

Feeling  of  distention.  Location ;  time  and 
duration  of;  relation  to  food. 

Pain.  Seat ;  character ;  boring,  colicky, 
cutting,  burning,  etc.;  time  of  occur- 
rence, circumscribed  or  diffuse ;  radia- 
tion ;  degree  ;  effects  of  pressure  ;  of  heat, 


22. 


food,    sodium    bicarb.      (Gastric    crises, 
gall-stones,  renal  colic.) 

Regurgitation  and  eructation.  Time ; 
degree  ;  consistence ;  character  ;  odor ; 
taste;  amount  of  fluid  regurgitated; 
regurgitation  of  food;  condition  of,  time 
of.     Rumination.     Hiccup. 

Nausea.     Time;  degree;  apparent  cause. 

Vomiting.  Time;  frequency;  relation  to 
meals ;  amount  and  character  of  vomi- 
tus ;  color,  taste  and  odor ;  food  eaten 
many  hours  before;  mucus;  bile;  blood, 
appearance.  Symptoms  accompanying 
^^omiting :  nausea,  pain,  weakness,  faint- 
ness,  colic,  cram.p.  Fecal  vomiting. 
Sensations  after  vomiting. 

Flatulence.  Duration  of ;  degree ;  constant 
or  variable ;  relation  to  food ;  noises  in 
abdomen.     Is  wind  passed  up  or  doAvn? 

Subjective  motions  in  abdomen :  seat :  rela- 
tion to  eating-.  Pulsations:  when  felt; 
degree. 

Stools.  Number  ;  character  ;  is  latter  con- 
stant or  variable?  If  constipation,  w^hat 
is  and  has  been  used  to  overcome  it? 
Appearance  of  stools. 

Pain  in  defecation.    Location,  character. 

Mucus,  pus  or  blood  in  stools;  describe  in 
patient's  w-ords. 

Hemorrhoids:  fissure;  fistula;  tenesmus. 


—  23  — 

Tumors,  masses,  "bunches"  (or  other 
terms  applied  to/iiew-growths)  in  abdo- 
men :  when  discovered ;  constant  or 
variable ;  size  and  change  of  size ;  pain ; 
position;  mobility. 

Pain  in  region  of  liver  or  gall-bladder; 
occurrence,  duration,  character,  degree. 

Jaundice.  Duration,  degree ;  associated 
symptoms ;  nervous  symptoms. 

13.    General.      Emaciation;    cachexia;    lymph 
glands. 

15.  Skin.     Color  and  other  condition  of  skin 

(naevi)  ;  examine  w^hole  body. 

16.  Head.    Tongue.    Teeth  in  detail.  Pharynx. 

17.  Neck.     Tumors   in  oesophagus;   stricture; 

spasms.  Examination  of  oesophagus; 
soft  tube ;  probe  (caution :  X-ray  first  1 
aneurysm!);  swallowing  murmurs. 

18.  Effusions  or  new-growths  in  thorax.    Lor- 

dosis ;  scoliosis ;  retraction. 

20.    Abdomen.     Size   and   shape   of   abdomen, 
both  lying  and  standing. 

Skin.  Texture,  color,  triae  ;  veins  ;  visible 
tumors;  patterns  of  tumidity;  pulsa- 
tions ;  peristaltic  motion. 

Palpation.  Thoroug'h,  with  reference  to 
position,  size,  shape  and  consistence  of 
all  organs. 


—  24  — 

Percussion.  (Not  so  valuable  as  palpation 
and  inspection,  but  can  often  add  to  pre- 
vious information.  Percussion  of  liver 
important  in  suspected  peritonitis.) 
Percussion  on  changing  position ;  in 
knee-hand  position.  Fluctuation  on  tap- 
ping with  fingers. 

Auscultation.  Gurgling;  succussion.  Fric- 
tion sound  over  liver  ;  murmur  in  abdom- 
inal veins. 

Stomach.  Inspection;  palpation,  percus- 
sion and  auscultatory  percussion  ;  suc- 
cussion (exact  position  of)  ;  distention  by 
air  or  by  other  method ;  note  curvatures. 
Stomach  tube  or  duodenal  tube.  Test 
meals,  shredded  wheat  biscuit,  bread  and 
water,  dinner.     For  scheme,  see  below. 

Intestines.  Distention;  peristalsis;  pat- 
tern ;  distention  of  colon  by  rectal  tube 
and  bulb  (x-ray  preferable).  Palpation 
for  tenderness,  rigidity,  and  tumors  ;  note 
all  characteristics.  Appendix.  Appen^ 
dix  region;  tenderness;  other  details. 

Liver.  Inspection,  palpation  (standing  as 
well  as  lying)  ;  percussion;  position  and 
outline  of  borders;  thickness  of  loAver 
edge  ;  surface  smooth  or  uneven  ;  scars  ; 
nodules;  tumors;  depressions;  abnormal 
lobes ;  friction ;  tenderness  on  pressure. 
Aspiration  of  liver  and  sub-diaphragm- 
atic space. 


—  25—  •        • 

Gall-bladder.  Position,  size,  shape,  con- 
sistence. 

Spleen.    Position,  size,  shape,  consistence. 

Pancreas.     Size,  shape  and  consistence. 

Palpation  and  auscultation  of  peritoneal 
friction  and  gurgling. 

Examination  of  anus  and  rectum.    Ulcers, 

fissures,  hemorrhoids,  fistula,  stenosis, 
inflammation  and  new  growth  in  the 
rectum.    Sites  of  herniae.    Pelvis. 

Palpation  of  tumors.  Position  in  abdomen 
and  in  relation  to  other  organs ;  size  (in 
exact  figures  or  plain  comparisons)  ; 
shape ;  surface ;  smooth,  even,  nodular ; 
consistency ;  hard,  soft,  fluctuating ; 
mobility;  spontaneous,  with  respiration, 
by  pressure ;  resistence  when  held  down 
in  inspiration ;  pain  in  tumor. 

22.  Urine.     Always  m.ake  complete  examina- 

tion of  urine.     Scheme  VI. 

23.  Blood.     Always  make  complete  examina- 

tion of  blood.     Scheme  V. 

24.  Stools  and  defecation.     Frequency;  quan- 

tity; color;  odor;  reaction;  consistence; 
if  formed ;  size  and  shape ;  presence  of 
foam  (in  relation  to  time  out  of  body)  ; 
mucus;  blood;  occult  blood  (method); 
pus ;  food  remains  ;  sloughs ;  parasites ; 
ova. 


—  26  — 

Microscopic  examination.  Food  remains; 
muscle  fibres ;  connective  tissue ;  vege- 
table fibres  and  cells  :  starch  ;  leucocytes ; 
red  blood  corpuscles ;  epithelial  cells ; 
crystals,  as  bismuth,  triple  phosphates, 
Charcot  crystals  (large  numbers  in  some 
cases  of  helminthiasis)  ;  vegetable  crys- 
•  tals  and  sand;  fat;  fatty  acids;  soap; 
bacteria ;  yeasts ;  protozoa ;  eggs.  Look 
for  tubercle  bacilli  in  all  cases  with  pus 
in  stools. 

Bile  coloring  matter  (bichloride  test). 

26,  Other  examinations  as  indicated,  including 
palpation  in  hot  bath  and  under  anaes- 
thesia. 

Scheme  for  Examination  of  Stomach  Con- 
tents. Fasting  contents  in  all  cases. 
Examine  and  note  as  for  test-meal.  Note 
food  previously  eaten.  Test-meal,  kind  ; 
time  after  eating.  Method  of  removal 
(stomach  tube ;  duodenal  tube ;  expres- 
sion, aspiration).  Quantity;  color:  odor; 
food-particles  ;  mucus ;  blood ;  bile. 

Lavage  after  removal,  results  of. 

Microscopic  examination.  Food  remains 
in  detail.  Blood-corpuscles;  leucocytes; 
bacteria  fdetails)  :  sarcines ;  yeasts ; 
molds;  protozoa;  epithelial  cells;  tissue 
fragments ;  "myelin." 

Filtrate.  Quantity ;  Sp.  G. ;  reaction  to  lit- 
mus ;  to  Congo  ;  Giinzberg's  phloroglucin 


—  27  — 

and  vanillin ;  dimethyl-amido-azo-ben- 
zole.  Lactic  acid  tests ;  Uffelmann ; 
(other  methods)'.  Acetone  (in  distil- 
late). 

Quantitative  tests.  Give  method ;  chart,  if 
fractional.  Free  HCl ;  total  acidity. 
Hydrogen  ions. 

Digestion  tests.  Pepsin  (rennin).  Results 
of  digestion  :  Albumoses  ;  peptones. 

Starch  digestion.  Erythrodextrin ;  mal- 
tose; dextrin. 

Absorption  tests. 

Motor  power  tests  (Fluoroscopy). 

Special  examination.  Fluoroscopy  and 
skiagraphy  of  gastrointestinal  tract 
(teeth,  oesophagus,  stomach,  small  intes- 
tine, appendix,  colon  (diverticulosis)  ; 
gall-bladder.  Diagnostic  pneumoperi- 
toneum. Duodenal  and  gall-bladder 
diagnostic  aspiration.  Esophagoscopic ; 
proctoscopic ;  sigmoidoscopic. 


V.  DISEASES  OF  METABOLISM,  BLOOD 
AND  DUCTLESS  GLANDS. 

3,  4.  Examine  family  and  personal  histories 
with  care. 

5.  Previous  conditions.  Investigate  histories 
if  possible  ;  stomach  diseases  ;  diarrhea  ; 
parasites  and  poisons ;  rickets. 


—  28  — 

6..  Note  injurious  mental  habits  or  emotions, 
shock,  business  reverses  and  strains. 

9.  Onset.  Note  especially  particulars  of 
weakness ;  changes  of  appetite  ;  hiinger ; 
thirst;  loss  of  weight;  gain  of  weight; 
vision ;  anomalies  of   sleep ;   impotence. 

11.  Present  Symptoms.     In  case  of  headache, 

note  characteristics ;  vertigo ;  tinnitus 
aurium  ;  epistaxis  ;  hemoptysis  ;  neural- 
gias ;  stomach  and  intestinal  symptoms 
in  detail. 

12.  Always  give  T.  P.  R.  and  status  praesens 

in  detail,  according  to  general  and  spe- 
cial schemes. 

13.  Ideal    v^eight;    habitus.      Distribution    of 

subcutaneous  fat;  fat  tumors.  Extrem- 
ities and  "ends"  (acra)  ;  nose;  chin; 
tongue,  etc.  Tremors,  writing  or  tracing. 

14.  Position;   appearance;   mind.     Note  fully 

all  details. 

15.  Skin.      Pigmentation;    depigmentation    of 

skin  ;  mucous  membranes  ;  edema  ;  myx- 
edema ;  scleroderma ;  vasomotor  anom- 
alies; trophic  changes;  itching:  urti- 
caria (hives)  ;  sweating;  flushing.  Tophi. 

16.  Head.     Eyes  and  eyelids;  Graefe's,  Stell- 

wag's  and  Moebius's  symptoms;  pupils 
and  their  reflexes.  Ophthalmoscope. 
Spacing  of  teeth ;  changes  in  ''bite." 
Hard  palate.     Salivary  glands. 


—  29  — 

ly.    Neck.    Pulsations ;  thrill.    Auscult  thyroid 
when  enlarged.    . 

i8.    Thorax.     Percuss  for  thymus. 

22.  Urine.     See  Scheme  VI. 

23.  Blood.     Fresh  drop :  flow ;  color,  consist- 

ence. Fresh  drop,  microscopic  ;  red  cells, 
size,  shape,  color,  relative  number,  rolls, 
Leucocytes,  relative  number,  other  char- 
acteristics. Platelets.  Fibrin.  Para- 
sites :  describe  fully. 

Number  of  red  cells. 

Number  of  leucocytes. 

Hemoglobin  (method  used)  ;  color  index. 
Specific  gravity  (method). 

Differential  count.  Stain.  Number  of  cells 
counted.  Small  lymphocytes  ;  large  lym- 
phocytes; transitional;  polynuclear; 
eosinophile  polynuclear;  eosinophile 
mononuclear  ;  myelocytes  ;  mast  cells ; 
degenerates ;  other  forms. 

Red  cells  ;  microcytes  ;  macrocytes  ;  micro- 
blasts  ;  normoblasts  ;  megaloblasts  ;  poi- 
kilocytes ;  vacuolated ;  punctate ;  poly- 
chromatophile  ;  Howell's  bodies  ;  Cabot's 
rings ;  Schiiffner's  granules ;  undeter- 
mined. 

Platelet  count. 

Coagulation  time ;  bleeding  time.  Viscos- 
ity.    Fragility. 


—  30  — 

Blood  chemistry:  Total  N,  non-protein 
N;  ammonia  N;  amino-acid  N;  uric 
acid  ;  creatinin  ;  sugar  ;  calcium  ;  chlo- 
rides. Total  solids.  CO..  combinins; 
power ;  O  affinity  of  Hb ;  H-ion  con- 
centration ;  lecithin  ;  total  fat ;  choleste- 
rol;  diastasic  activity;  plasma  COo ; 
alkalinity;  Na  feeding  test. 

27.  Special  examinations.  Skiagram  of  skull 
(sella);  long  bones;  joints;  vertebrae. 
Excision  of  specimens,  skin,  subcutane- 
ous, hanph  nodes  for  histologic  exam- 
inations. Pharmacodynamic  tests.  Pro- 
tein sensitization.  Alveolar  air,  COo 
tension  of.  Basal  metabolism.  Sugar 
tolerance  curve   (give  data). 


VI.    DISEASES  OF  THE  URINARY  AND 
SEXUAL  ORGANS. 

3.  Family  history.     Details  as  to  diseases  of 

eenital  and  urinarv  ors^ans  in  immediate 
family. 

4.  In  women.     Complications  in  vagina,  ute- 

rus, bladder  or  kidneys  in  pregnancy  or 
puerperium. 

5.  Previous  condition.     Exposure  to  cold  and 

wet. 

7.    Sexual.      In    detail,   with   care   in   putting 
questions. 


—  31  — 

g.  Onset.  Earliest  appearance  of  pallor  ;  dys- 
pnoea ;  oedema  of  face,  feet,  hands,  body; 
weakness  ;  headache  ;  vertigo  ;  eye  symp- 
toms ;  epistaxis;loss  of  appetite;  gastric 
symptoms  in  detail ;  pain  in  back  ;  altera- 
tions of  micturition ;  pain  in  urinary 
tract ;  unusual  appearances  in  urine ;  dis- 
charges from  genitals,  characters  of. 

i6.    Head.    Arteries,  eyegrounds. 

i8.  Thorax.  Bronchitis  ;  emphysema  ;  hydro- 
thorax. 

ig.  Heart.  Complete  examination  ;  notice  sec- 
ond aortic  sound;  pulse,  ^  tension: 
(SphygmomanomxCter.) 

20.  Abdomen.     Ascites. 

21.  Full  examination  o£  genito-urinary  appa- 

ratus. Prostate  and  seminal  vesicles; 
massage ;  2  or  3  glass  test.  Cystoscope ; 
ureteral  catheterization. 

22.  Scheme  for  Examination  of  Urine. 

Quantity.  When  passed,  as  sample,  giving 
time  of  day;  day  or  night;  24  hours. 
(Bladder  must  be  emptied  at  end  of 
every  period.     If  per  catheter,  note.) 

Specific  gravity ;  reaction  ;  color  ;  odor ; 
clear  or  turbid ;  floaters  (make  film, 
stain,  examine,  describe). 

Albumin  tests.  Boiling  and  dilute  acetic 
acid ;  Heller's ;  acetic  acid  and  ferrocy- 


—  32  — 

anide;  other  methods.  For  quantitative, 
note  bulk  after  boiling  and  acid,  in  vul- 
gar fractions,  or  Esbach  (Tsuchiya)  ; 
Kjeldahl. 

Albumose;  Bence-Jones  proteid.  Globu- 
lin ;  mucin. 

Glucose  tests,  a,  Fehling's  (Benedict)  ;  b, 
boiling  with  KOH  solution ;  c,  phenyl- 
hydracin ;  d,  fermentation  ;  e,  polariscope. 
For  quantitative,  Benedict,  d,  e. 

Bile  coloring  matter.  Foam;  Gmelin  ;  Uro- 
bilin ;  urobilinogen. 

Bile  acids.  Hemoglobin;  indican  ;  acetone; 
diacetic  acid ;  beta-oxybutyric  acid  ;  hae- 
matoporphyrin  ;  melanin;  leucin  ;  tyro- 
sin;  alkapton ;  H^S;  cystin;  phenol; 
pyrocatechin ;  hippuric  acid. 

Quantitative  tests.  Total  acidity  and  alka- 
linity; chlorides;  sulphates,  inorganic, 
conjugated,  neutral  sulphur;  phos- 
phates ;  total  N ;  non-protein  N ;  urea ; 
uric  acid ;  ammonia ;  creatinin  :  creatin ; 
alloxur  Tpurin)  bases;  oxalic  acid;  indi- 
can ;  oxybutyric  acid ;  acetone  bodies ; 
hydrogen-ion  concentration. 

Sediment.  (Fresh  specimens.)  Amount; 
color;  appearance.  Mucus.  Centrifu- 
gate ;  amount  and  macroscopic  appear- 
ance. Epithelial  cells,  number  and  kind ; 
leucocytes,  number  and  kind;  red-blood 
cells,   number   and   condition;   crystals; 


—  33  — 

casts,  number  and  kinds  (urates ;  uric 
acid  ;  calcium  oxalate  ;  phosphates  ;  car- 
bonates) ;  cylindroids  ;  spermatozoa ;  bac- 
teria, number  and  kind  (tubercle-,  smeg- 
ma-) ;  protozoa ;  animal  parasites ; 
embryos ;  ova. 

23.    Blood.  '  Complete  blood  chemistry. 

27.  Functional  tests.  Phenol-sulphone-phtha- 
lein;  lactose;  sodium  chloride;  potas- 
sium iodide ;  concentration  diuresis. 

Special  examinations.    Pyelograms.    Skia- 
grams for  calculi. 


VII.    DISEASES   OF  THE  NERVOUS 
SYSTEM. 

{.  Family  history.  Careful  investigation  of 
family  history  for  nervous  and  mental 
diseases.  Congenital  abnormalities. 
"Nervousness"  (peculiarities  of^  ;  neu- 
rasthenia ;  epilepsy ;  insanity ;  drunken- 
ness ;  syphilis ;  suicide  (assigned  cause)  ; 
deaf  mutism  ;  precociousness  ;  brilliancy ; 
talents  ;  eccentricities  ;  marriage  of  blood 
relations.  Health  of  latter.  Effect  of 
narcotics  and  alcohol.  History  of  rapid 
success  ;  failures  ;   disappointments. 

4.  In  women.  Full  history  of  menstruation ; 
pregnancy ;  abortion  ;  confinement ;  puer- 
peral disease;  pelvic  disease. 


—  34  — 

5-  Injury  or  disease  at  birth.  (Birth  palsy)  ; 
convulsions;  syphilis;  dentition;  closure 
of  fontanelles ;  growth;  time  of  begin- 
ning to  walk ;  symptoms  at  puberty  and 
early  adult  life;  accidents;  injuries:  sen- 
ility (symptoms)  ;  headache  ;  apoplexy  ; 
epilepsy;  paralysis. 

Temperament ;  disposition ;  change  of  dis- 
position (often  noticed  by  others  than 
patient  or  relatives)  ;  extravagance  in 
plans  or  expenditure. 

6.  Occupation  and  Habits.     School  history; 

Overwork;  exercise;  rest.  Use  of  pois- 
ons and  narcotics,  especially  alcohol, 
morphine,  heroin,  chloral,  cocaine,  ether. 

7.  Sexual  Life.    Often  essential  to  investigate 

closely.  Masturbation  ;  sexual  excesses ; 
perversions ;  failure  of  sexual  power. 

8.  Present  disease;  repressed  desires;  moral 

or  physical  shock.  Business  cares,  over- 
exertion, fright. 

9.  10.    Under  Course  and  Present  Symptoms 

describe  symptoms  in  sequence.  Note : 
Pain,  location  and  character;  pain  on 
pressure ;  hyperesthesia ;  hyperalgesia ; 
radiation  of  pain;  e.  g.,  in  trigeminal 
neuralgia;  sinusitis;  otitis  media;  reflex 
symptoms,  as  cough  in  irritation  of  pos- 
terior portion  of  Eustachian  tube,  pain 
in  back  on  aspiration  of  foreign  body, 
polyesthesia     in     spinal     cord     disease; 


—  35  — 

hyperesthetic  zones;  anesthesia;  pares- 
thesia (numbness,  formication)  ;  tics ; 
tremors;  tetany;  spasmophilia;  contrac- 
tions, fibrillary;  contractures;  convul- 
sions, tonic,  clonic;  epilepsy;  hysteria; 
catalepsy;  aura;  paralysis  (details)  ;  loss 
of  memory;  alterations  of  sleep;  disturb- 
ance of  vision ;  double  vision ;  tinnitus 
aurium ;  dysphagia ;  disturbance  of 
speech ;  vomiting-  (details)  ;  gastric 
crises. 

Subjective  Sensations. 

a.  Referable  to  face  or  extremities,  ting- 
ling, etc. 

b.  Vision  (colors,  rotation  of  person  or 
surrounding  objects.  Side  from  which 
appear  objects,  persons,  etc.  Dizzi- 
ness. 

c.  Hearing. 

d.  Taste. 

e.  Smell. 

f.  Dreamy  states. 

Upper  Extremities.    Loss  of  power  or  par- 
tial paralysis. 
Changes  in  sensation. 
Tremors;  changes  in  nails;  unusual  per- 
spiring. 

Abdomen.    Bladder  or  rectal  symptoms. 
Paradoxical      incontinence ;      retention ; 
true  incontinence. 


-36- 

Lower  Extremities.  Loss  of  power,  change 
in  sensation. 

Tremors,  changes  as  above. 
Gait,  tendency  to  fall,  and  how. 

13.  Body  in  general.    Abnormalities  and  defor- 

mities ;  stigmata.  Trophic  changes  in 
bones' and  joints. 

14.  Under    mental     condition     describe    fully 

whether  mind  is  clear  or  clouded ;  exalted 
or  depressed ;  coma ;  stupor ;  delirium  (d. 
of  grandeur)  ;  present  disposition  ;  atten- 
tion ;  memory;  lethargy;  narcolepsy. 

Speech.     Anarthria ;  aphasia. 

Writing  (voluntary,  by  dictation  and  copy- 
ing)- 

Gross  Localization.  Cerebral  cortex.  Par- 
alysis, flaccid,  spastic;  describe  localiza- 
tion ;  cutaneous  sensibility ;  muscle 
sense:  astereognosis;  visceral  sensa- 
tions.    Spasm,  Jacksonian  epilepsy. 

Centrum  semiovale. — Paralysis ;  sensory 
disturbance ;  aphasia ;  neighborhood 
symptoms:  distal  symptoms;  shock 
symptoms.     Diaschisis. 

Corpus  striatum. — Wilson's  disease :  paral- 
ysis agitans ;  Huntington's  chorea. 

Corpus  callosum. — Apraxia. 

Thalamus. — Thalamic  syndrome  ;  hemian- 
opsia. 


—  37  — 

Internal  capsule. — Hemiplegia  ;  hemianes- 
thesia. 

Crura. — Spastic  paralysis ;  crossed  paraly- 
sis ;  Weber-Gubler  syndrome ;  hemianop- 
sia :  ataxia ;  disturbance  of  hearing ; 
oculo-motor  paralysis;  NothnageFs  syn- 
drome. 

Corpora  quadrig-emina. — Pupillary  reac- 
tion ;  auditory  disturbance ;  mastication 
affected;  ataxia. 

Pons  and  Medulla. — Crossed  paralysis ; 
motor  or  sensory ;  spastic  paralysis ; 
abducens  or  hypoglossus  paralysis ; 
anarthria;  deglutition  disturbance;  con- 
jugate paralysis  of  eyes;  dissociated  sen- 
sory disturbance ;  tetraplegia. 

Cerebellum. — Ataxia ;  hypotonia  ;  asthenia ; 
volitional  tremor ;  vertigo ;  disturbance 
of  equilibrium;  nystagmus.  Rebound 
phenomenon ;  adiodochokinesis  ;  point- 
ing test ;  attitude ;  gait ;  ocular  disturb- 
ance ;  atonia  ;  asthenia  ;  astasia. 

Hypophysis.  Signs  of  hypo-  or  hyperpi- 
tuitarism. Bone  changes  of  hands,  feet 
or  face,  teeth,  palate ;  bitemporal  blind- 
ness ;  skin ;  genitals ;  hair  on  body ;  adi- 
posity; sugar  tolerance,  alterations  of. 

Skin.  Scars  as  evidence  of  syphilis.  Skin, 
color  of ;  local  alterations  of  color  and 
temperature  ;  visible  mucous  membranes, 
color ;    local    cyanosis    and    congestion ; 


-38- 

sweating;  glossy  skin;  scaly  skin;  exan- 
themata ;  edema  ;  hemorrhage  ;  pigmen- 
tation ;  atrophy ;  ulceration.  Nails : 
lunula  ;    surface  ;   thickness  ;   brittleness. 

i6.    Head.    Shape  of  head  in  detail.    Pain  ;  pain 
on  pressure  or  tapping.    Auscultation. 
Face.  Symmetry    of    halves.       Forehead, 
wrinkles  of,  symmetry.     Twitching. 

Cranial  Nerves. 

Nose.     Nostrils;  nasolabial  folds. 

I.  Smell  (both  sides). 

Eyes.  Lids,  motion  of ;  tension  of  bulb ; 
motion  of  eyes,  up,  down,  left,  right; 
convergence  ;  nystagmus.  Pupils  :  diam- 
eters ;  reflexes  to  light  and  accommoda- 
tion. Ophthalmoscope.  Color  sense. 
Tears. 

II.  Vision  and  color  fields,  scotoma; 
hemianopsia. 

Ill,    IV,   VI.     Ocular   movements ;    diplo- 
pia. 

V.    Sensory.     Sensation  of  face  and  cor- 
nea. 
Motor.     Mastication. 

VII.  Atrophy  or  paralysis ;  herpes ; 
sweat,  anomalies  of;  conjunctivitis. 

Ears.     Hearing;  aural  speculum. 

VIII.  Cochlear.  Bone  and  air  conduc- 
tion. Vestibular.  Rotation  tests. 
Caloric  tests.     Barany  test; 


—  39  — 

Mouth,     Straight  or  crooked;  movements 
of  lips,  as  in  AvhistHng-;  laughing;  blow- 
ing ;  chewing.     Teeth. 
IX.    Taste. 

Vault  of  Palate.     Saliva. 
X. 

Soft  Palate.  Velum.  Laryngoscope  in 
case  of  alterations  of  voice;  laryngeal 
muscles  ;  tumors ;  ulcers. 

Tongue.      Position,    protrusion  ;    atrophy  ; 
hypertrophy ;  tremor ;  fibrillary  tremor. 
XL    Sternomastoid ;  trapezius. 
XIL    Movement  of  tongue. 

Movements  of  neck :  to  right ;  left ;  nod- 
ding; turning;  resistance  of  neck;  stiff 
neck.  Vertebrae,  cervical;  tenderness; 
deformity.  Thyroid  gland :  Atrophy, 
goitre. 

Thorax.  Dorsal  and  lumbar  vertebrae ; 
shape:  rigidity;  pain  on  pressure. 

(a)  Special  examination  of  muscles  and 
nerves. 

Shoulder.  Nutrition.  Scapulae,  position. 
Arms  and  hands,  nutrition ;  position 
(drop  wrist)  ;  thenar  and  hypothenar 
eminences ;  interosseous  muscles. 

Motor  power  of  arms.     Raising  shoulders. 

Arms.  Rotating  arms;  Forearm:  Flex; 
extend  ;  pronate  ;   supinate. 


—  40  — 

Hands  and  fingers.  Flex  and  extend ; 
spread  lingers.    Hypotonus  ;  hypertonus. 

Thumbs.  Movements.  Grip :  Both  hands. 
Ataxia ;  finger-nose  test ;  finer  coordina- 
tion movements. 

Thighs.      Flex,    abduct;    adduct;    rotate. 

Legs.     Nutrition  ;  position  ;  trochanters. 
Leg :  flex,  extend.     Power  of  walking. 

Feet.     Flex,  extend.     Toes,  same. 

Complicated  movements.  Ataxia;  tremors, 
kind ;  equilibrium  with  eyes  closed ; 
walking  with  eyes  open  and  closed; 
Motion  of  legs  while  lying,  with  eyes 
open  and  closed ;  crossing  legs ;  walking 
movements :  heels  on  opposite  knees ; 
describe  circles  with  leg. 

Hands.  Touch  nose,  chin  and  forehead. 
Writing. 

Electric  examination  of  motor  nerves  and 

muscles :  see  text-books  on  diagnosis. 
.  Palpation  and  percussion  of  nerve-trunks. 

Sensation,  objective  tests.  Gentle  touch ; 
moderate  touch  ;  pinching ;  pricking ;  dif- 
ference between  point  and  head  of  pin ; 
electric  current.  Temperature;  deep 
sensation ;  point  sensation. 

Pressure.  Cold  and  heat.  Localization  of 
sensations.  Stereognosis.  Muscle  sense 
(weights) . 

Passive  motion. 


41 


Reflexes.  Skin  and  mucous  membrane ; 
sole ;  palm  ;  cremaster  ;  abdomen  ;  eye- 
lid ;  sclerae ;  palate ;  tendon  and  perios- 
teum; patellar;  Achilles;  foot-clonus; 
Babinsky;  Oppenheim;  Gordon;  Chad- 
dock;  adductors;  biceps;  triceps;  jaw. 

Kernig's  sign;  Brudzinski. 

Abdomen.     Shape  (retraction  in  meningi- 
tis) ;  reflexes ;  sensation. 
Rectum.     Paral3^sis. 

Genito-urinary.  Examine  bladder ;  incom- 
tinence ;  retention ;  frequent  micturition. 

Spinal  puncture.  Pressure ;  appearance. 
Microscopic  :  Cells,  number  and  kind  ; 
bacteria,  other  organisms.  Wasser- 
mann. 

Chemical.  Globulin;  sugar;  colloidal  gold 
curve. 

Special  Examination.  Mental  tests ;  ven- 
tricular puncture;  skiagram;  injection  of 
air  in  ventricles. 

Cystoscopic  (neurogenic  bladder). 


—  42  — 

SCHEME  FOR  THE  EXAMINATION 
OF  SENSIBILITY. 

(After  Head  and  Holmes.) 

A.  Spontaneous  Sensations, 

Pain,  numbness,  tingling. 

Position  of  the  limb.     Idea  of  the  limb. 

B.  Loss  of  Sensation. 

1.  Touch. 

(a)  Light  touch. 

Cotton-A^'ool  on  hairless  and  hair-clad 

parts. 
Threshold  with  von  Frey's  hairs. 

(b)  Pressure  touch. 

Threshold    with    the   pressure-aesthe- 

siometer. 

2.  Localization. 

Naming  the  part  touched. 
Henri's  method,  as  miodified  by  Head  and 
Holmes. 

3.  Roughness. 

Threshold  Avith  Graham-Brown's  aesthe- 
siometer;  sand-paper  tests;  discrimina- 
tion of  relative  roughness. 

4.  Tickling  and  scraping. 

Tickling  on  soles  and  palms. 
Cotton-wool  rubbed  over  hair-clad  parts. 
Light  scraping  with  the  finger  nails. 


—  43  — 

5-    Vibration. 

Loss  or  diminution  of  sensibility. 

Alteration  in  the  character  of  the  sensa- 
tion evoked. 

6.  Compasses. 

Points  simultaneoiisly,applied. 
Points  successively  applied. 

7.  Pain. 

(a)  Superficial  pain. 
Pin-prick. 

•  Threshold  with  the  algesimeter. 
Reaction  to  measured  painful  stimuli. 

(b)  Pressure  pains. 

Threshold  with  the  algometer. 
Reaction  to  painful  pressure. 

8.  Temperature. 

Threshold  for  heat  and  cold. 

Effects  of  adaptation  on  the  threshold. 

Discrimination  of  different  degrees  of  heat 
and  cold. 

Affective  reactions  (a)  to  extreme  degrees; 
(b)  to  warmth. 

9.  Positions. 

By  imitating  with  the  sound  limb  the  posi- 
tion of  the  aff'ected  limb. 

By  pointing  with  the  sound  limb. 

Measurement  of  defect  by  Horsley's 
method. 


—  44  — 

10.  Passive  Movement. 
Appreciation  of  movement. 
Recognition  of  direction  of  movement. 
Measurement  of  the  angle  of  the  smallest 

movement  which  can  be  appreciated. 
Falling    away    of    the    unsupported    limb 
when  the  eyes  are  closed. 

11.  Active  Movement. 

Imitation  of  movement  by  sound  limb. 
Ability  to  touch  known  spot. 
Measurement  of  the  defect  by  Horsley's 
method. 

12.  Weight. 

(a)  With  the  hand  supported : 
Recognition   of  differences  in  weight 

applied  successively  to  one  hand. 
Appreciation  of  increase  or   decrease 

of  weight. 
Comparison    of    two    weights    placed 

one  in  each  hand. 

(b)  With  hand  unsupported : 
Comparison  of  two  weights  placed  one 

in  each  hand. 
Recognition  of  differences  in  weights 
applied  successively  to  one  hand. 

13.  Size. 

Difference-threshold. 

Distinction  of  the  head  from  the  point  of 
pin. 


—  45  — 

14.  Shape.     (Two-dimensional.) 

15.  Form.     (Three-dimensional.) 
Recognition  of  common  objects  by  their 

form. 

16.  Texture. 

17.  Dominoes. 

Ability  to  count  points  by  touch. 

18.  Consistence. 

19.  Testicular  sensibility. 

Light  pressure. 
Painful  pressure. 

20.  Sensibility  of  the  glans  penis. 


-46- 

ROUTINE    WARD    AND    LABORATORY 
WORK    IN    MEDICAL    WARDS. 

All  Patients — on  Admission. 

1.  Complete  history  as  per  outline, 

2.  Physical  examination. 

3.  Red  blood  count ;  white  blood  count. 
Hemoglobin  estimation. 

4.  Blood  for  Wassermann. 

5.  Urine  analysis. 

6.  Stool  examination. 

7.  Sputum  examination  (all  sputum  must 
be  examined). 

8.  Blood  pressure ;  on  leg  also  if  high  pres- 
sure. 

9.  Phenol-sulphone-phthalein. 

The  above  must  be  completed  on  each  case 
before  Medical  Rounds  at  9  a.  m.  the  m.orning 
following  admission  to  the  hospital. 

Special  Cases. 

Typhoid  Fever. 

1.  AVhite  blood  count  every  other  day,  or 
oftener  if  indicated. 

2.  Red  blood  count  once  a  week. 

3.  Hemoglobin  once  a  week  and  at  once  on 
suspicion  of  hemorrhage. 

4.  Urine  analysis  every  day  (diazo,  acetone 
bodies). 


—  47  — 

5-  Blood  pressure  every  day,  and  at  once  on 
suspicion  of  perforation  or  heniorrha2:"e. 

6.  Stools.  First  stools  and  all  suspicious 
stools  must  be  sent  to  laboratory  and  exam- 
ined.    (Infectious — handle  with  care.) 

7.  Blood,  stool  and  urine  cultures  and  Widal 
test  by  laboratory  staff;  note  results. 

8.  Fluid  intake  and  output  charts. 

9.  Food  calories  daily. 

Pneumonia. 

1.  White  blood  count  every  day. 

2.  Red  blood  count  once  a  week. 

3.  Hemoglobin  once  a  week. 

4.  Urine  analysis  every  day  (quantitative 
chloride). 

5.  Blood  pressure  every  day  (systolic,  dias- 
tolic)   (a.  m.  and  p.  m.). 

6.  Sputum  and  sputum  cultures  and  typing 
by  laboratory  staff;  note  results. 

Malaria. 

1.  Blood  examination  every  day  (concen- 
tration method).  Fresh  and  stained  specimens. 
All  blood  smears  (stained)  must  be  carefully 
labelled  with  patient's  name,  date,  diagnosis, 
and  given  to  Ward  Doctor. 

2.  White  blood  count  daily  during  fever  and 
twice  a  week  at  same  time  of  day. 

3.  Red  blood  count  daily  during  fever  and 
twice  a  week. 


-48- 

4-    Hemoglobin  twice  a  week. 

5.  Blood   pressure    daily   during   fever   and 
twice  a  week, 

6.  Urine   analysis    twice   a   week ;   daily,   it 
abnormal. 

Diabetes. 

1.  Red  blood  count  once  a  week. 

2.  White  blood  count  once  a  week. 

3.  Hemoglobin  once  a  week. 

4.  Urine  analysis  every  day. 

(a)  Keep  a  chart  of  quantitative   sugar 
output.     Grams  per  liter.     Per  cent. 

(b)  Total  output  (grams)   per  24  hours. 

(c)  Acetone ;  diacetic  acid  ;  beta-oxybuty- 
ric  acid. 

(d)  Total  N  determination  (D  :N  ratio). 

(e)  Microscopic  examination  of  urinary 
sediment. 

5.  Keep  chart  of  special  dietary  measures, 
with  daily  special  laboratory  findings. 

6.  Alveolar  air  and  blood  CO^  by  staff  of 
Chemical  Laboratory. 

Pulmonary  Cases. 

1.  Red  blood  count  once  a  week. 

2.  White  blood  count  once  a  week. 

3.  Hemoglobin  once  a  week. 

4.  Blood  for  complement  fixation. 

5.  Urine  examination  twice  a  week;  daily,  if 
abnormal. 


—  49  — 

6.  Sputum  examination  every  day.  Note 
amount. 

(Elastic  tissue,  Tbs.,  pneumococci,  influenza 
bacilli.     Dark  field  for  spirochetes.) 

7.  Examination  of  pleural  fluid,  whenever 
obtained. 

(a)   Amount,   character,   specific  gravity. 
Albumin   (quantitative). 

(b)   Cytological   examination   in   citrate 
specimen.     Culture.     Inoculation. 

8.  Tuberculin  tests  only  when  ordered. 
Preserve     slides,     carefully     labelled,     with 

patient's   name   and   date,   and   give   to   Ward 
Doctor. 

Also  set  aside  50  cc.  of  fluid  for  special  exam- 
ination. Add  small  amount  of  toluol  for  pres- 
ervation. 

Gastro-Intestinal  Cases. 

1.  Red  blood  count  once  a  week, 

2.  White  blood  count  once  a  week. 

3.  Hemoglobin  once  a  week. 

4.  Differential  count  (500  cells)  as  re- 
quested. 

5.  Stool — careful  examination  of  each  speci- 
men sent  to  clinical  laboratory. 

6.  Examination  of  contents  of  fasting  stom- 
ach.    (First  examination  by  Ward  Doctor.) 

7.  Test  meals.  Analysis,  as  requested.  Spe- 
cial chart. 

8.  Duodenal  and  bile  tests. 


—  50  — 

Cardio-Nephritic  Cases. 

1.  Cardio-renal  charts;  pulse  deficit  chart. 

2.  Red  blood  count  once  a  week. 

3.  White  blood  count  once  a  week. 

4.  Hemoglobin  once  a  week. 

5.  Blood  pressure  every  day. 

6.  P.  S.  P.  and  N.  P.  N.  as  ordered. 

7.  Daily    urine    examination    (separate    day 

and  night  specimens). 

(a)  Careful  microscopic  examination 
(cells,  casts,  crystals). 

(b)  Quantitative  albumin  estimation 
every  day  (Esbach,  Tsuchiya's  rea- 
gent). 

(c)  Special  examination  in  chemical  lab- 
oratory.   Note  results  daily. 

8.  Stool  examination  (whenever  specimen  is 
sent  to  clinical  laboratory). 

9.  Tracings  to  be  taken  by  Ward  Doctor. 

10.  Electrocardiograms    and     special    vital 
capacity  tests  by  Heart  Station. 

Blood  Cases. 

Anemias ;     leukemias ;     Hodgkin's     dis- 
ease ;  polycythemia. 

1.  Red    blood    count;    white    blood    count; 
hemoglobin  estimation;  color  index. 

2.  Differential  count  (500  cells). 

3.  Fresh     and     stained    blood     smears     (as 
ordered  by  Ward  Doctor). 


—  51  — 

4-  Vital  stains  ;  fragility ;  peroxidase  :  coag- 
ulation time;  bleeding  time,  platelets. 

All  blood  smears  (stained)  must  be  carefully 
labelled  with  patient's  name,  date,  diagnosis, 
and  given  to  Ward  Doctor. 

5.  Grouping.  (Always  to  be  controlled  in 
biologic  laboratory.) 

6.  Gastric  analysis. 

7.  Duodenal  contents  ;  pigment. 

8.  Urine  analysis  twice  a  week.  (Occur- 
rence of  urobilin  or  urobilinogen.) 

9.  Stool  examination   (parasites,  blood). 

Ductless  Gland  Cases. 

1.  Pharmacologic  tests  by  expert;  keep 
notes. 

2.  Sugar  tolerance  in  chemical  laboratory. 
Note. 

3.  Basal  metabolism  in  chemical  laboratory. 
Note. 

4.  Photographs  and  x-rays. 

Neurological  Cases. 

Complete  medical  routine. 
Special  neurologic  examination. 
Lumbar  puncture  only  as  ordered. 

DIAGNOSIS  AND  CONTINUATION. 

Tentative  diagnosis  should  be  written  as 
soon  as  made,  beginning  with  the  end  of  the 
anamnesis.     All  positive   diagnoses,   including 


those  of  consultants,  are  to  be  written  in  the 
space  designated  on  the  front  history  sheet. 
Daily  notes  should  include  subjective  symp- 
toms, physical,  laboratory  and  special  exam- 
ination, requests  for  consultations,  all  prognos- 
tic statements  to  patients  or  others,  and  all 
therapeutic  measures,  with  statements  as  to 
effects.  Orders  other  than  routine  and  diag- 
nostic procedures  should  be  entered  in  the  front 
sheet,  under  "Remarks,"  when  ordered,  and 
results  entered,  briefly,  when  made,  with  date. 

All  laboratory  findings  are  to  be  charted  on 
history  same  day  as  examination  is  made. 
Report  all  unusual  findings  to  Ward  Doctor 
at  once. 

All  unknown  objects  must  be  shown,  also  all 
positive  specimens. 


—  53  — 

ABBREVIATIONS  PERMITTED. 

General. 

R.  =z=  right. 
L.  =  left. 

C.  C.  =  chief  complaint. 
F.  H.  =  family  history. 
M.  =  mother ;  f.  =  father ;  s.  =  sister ;  b.  = 
•  brother.    Number  for  order  of  birth;  i.  e., 
bi,  b2,  SI,  etc. 
1.  =  living;  w.  =  well ;  d.  =  dead. 
Numbers  only  in  Arabic  figures. 
P. .  I.  =  present  illness. 
P.  S.  =  present  symptoms. 
S.  P.  =  status  praesens. 

Head. 

m.  m.  =mucous  membrane. 
L.  and  Ace.  ■=  Ijght  and  accommodation. 
(Reference  to  reaction  of  pupils.) 

Thorax. 

Lungs — 

V.  F.  =  vocal  fremitus. 
B.  S.  =  breath  sounds. 
P.  N.  t=  percussion  note. 
W.  =  whisper. 
S.  V.  =  spoken  voice. 

Heart — 

P.  M.  I.  =  point  of  maximal  impulse. 

M.  S.  L.  =  mid-sternal  line. 

I.  C.  S.  =  intercostal  space. 

R.  C.  D.^=  relative  cardiac  dulness. 

A.  C.  D.  =  absolute  cardiac  dulness. 


—  54  — 

Ao  =  aortic  second  sound. 
P2  =  pulmonic  second  sound. 
EKG.  =  electrocardiogram. 

Pulse — 

f .  and  r.  ^  force  and  rhythm. 
y.  AV.  =  vessel  wall. 
B.  P.  =  blood  pressure. 

Abdomen. 

R.  M.  =  respiratory  movement. 

R.  H.  D.  =  relative  hepatic  dulness. 

R.  I.  F.  =  right  iliac  fossa. 

L.  I.  F.  =  left  iliac  fossa. 

M.  L.  =  mid  line. 

A.  S.  S.  =  anterior  superior  spine. 

Extremities. 

K.  K.  =  knee  kicks  (jerks). 

Dr.  J.  J.  Singer's  Symbols  for  Physical  Signs 
in  Lungs. 

B.  S.++ =  i^^ormal  breath  sounds. 
B.  S.-j-  =  decreased  breath  sounds. 

B.   S.  +  +  +  or     more,     increased     breath 

sounds. 
W.  S.+  ^  normal  whisper. 
W.  S.++ ^increased  whisper,  etc. 
W.  S. —  =  absent  whisper. 
M.  S.  =  muscle  spasm ;  -f-  marks  to  indi- 

cate  degree. 

//////    =  impaired  resonance. 
=  dulness. 
=  flatness. 


%Go^Oo    =  rales. 


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